Written by Caitlin Nicholson
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For sympathetic crashing acute pulmonary edema (SCAPE), noninvasive positive pressure ventilation (NIPPV) and high-dose nitroglycerin are key, while routine diuretic use is often not best.
How to eSCAPE this high pressure situation…
This narrative review evaluates evidence-based approaches for managing SCAPE in emergency settings. Using a narrative review, it identifies SCAPE as severe rapidly progressive acute pulmonary edema with hypertension and hypoxemia caused by afterload increase and fluid maldistribution. Key findings include the efficacy of NIPPV in reducing intubation (RR 0.49, CI 0.38-0.62) and high-dose nitroglycerin boluses in improving outcomes such as ICU admission rates (37.9% vs. 80%). Diuretics are reserved for volume overload cases. The identified treatment goal is to target a systolic blood pressure of less than 140–160 mmHg to improve symptoms like dyspnea.
How will this change my practice?
I will continue to prioritize high-dose nitroglycerin, as studies demonstrate that boluses (500–2000 micrograms) or rapid infusions (400–800 micrograms/min) are the preferred approach for effective blood pressure reduction, improved clinical outcomes, and safety. Additionally, I will consider adding clevidipine or nicardipine if nitroglycerin and NIPPV fail, with clevidipine being preferred due to its shorter duration of action. I may also consider IV enalaprilat to lower arterial resistance and increase venous capacitance by inhibiting the renin-angiotensin system.
Source
Emergency medicine updates: Sympathetic crashing acute pulmonary edema. Am J Emerg Med. 2025 Jan 5;90:35-40. doi: 10.1016/j.ajem.2024.12.061. Epub ahead of print. PMID: 39799613
